What Is the Impact of Integrated PC Programs on Patients?
Integrating PC into the outpatient oncology setting introduces palliative medicine and the PC team earlier in the course of a patient's illness, allowing for a smoother transition from curative to palliative goals of care when needed. Patients also will benefit from expert symptom management in the outpatient setting, which may result in fewer hospital admissions for severe symptoms, such as intractable pain or vomiting. The PC team can help to coordinate outpatient services, such as home health agencies and hospice services, or other resources available based on the patient's needs. As a result of this combination of palliative and oncology efforts into cancer care, patients will have the opportunity to receive the highest quality of care possible.
What Is the Impact on Healthcare Providers?
Having PC available in their outpatient practice allows oncologists the option of allocating symptom-management and goals-of-care discussions to their palliative colleagues, thereby enabling oncologists to focus on evaluation, staging, and management of cancer. In essence, this collaboration allows the oncologist to focus on oncology and the PC team to focus on the palliative aspects of cancer care. Several Quality Oncology Practice Initiative (QOPI) measures developed by the American Society of Clinical Oncology (ASCO) involve palliative oncology issues and are areas of care in which integration of PC into the outpatient oncology realm can be an indispensible asset. Thus, adding palliative expertise to the care of oncology patients enhances the overall quality of cancer care that the oncologist delivers, increasing the satisfaction of patients and providers.
Challenges of integrating PC into oncology care include lack of an appropriately sized workforce and lack of appropriate financing. There are both an acute and chronic workforce shortage of nurses, physicians, social workers, chaplains, and certified nursing assistance—essentially all members of the interdisciplinary team. Lupu and her expert panel noted that there are about 4400 hospice and palliative medicine (HPM) physicians in the US, but most practice part-time. They estimated that 10,810 full-time palliative and 4487 full-time hospice physicians were needed, translating to a shortage of 6000 to 18,000 palliative doctors. According to the current need, medical oncologists are also facing a 40% shortfall in personnel, so PC professionals may be able to make up for some but not all of the workforce deficits.
There are important clinical issues to be discussed before starting an integrated PC program. When doctors disagree on the treatment plan (eg, the oncologist wants to continue chemotherapy in accordance with patient and family wishes but the PC doctor believes the chemotherapy should be stopped), how will the conflict be managed? We strongly suggest that such problems be addressed beforehand.
What Is the Impact on the Healthcare System?
Generally, the impact on the healthcare system of integrating PC into oncology care appears to be positive; however, it is important not to make assumptions about benefits. Passik et al described the consequences of “moving upstream” to capture PC patients early, before referral to hospice. This “PC-to-hospice” group was more complicated to manage and more costly to the hospice ($413.15 vs $332.05 per patient in the direct-to-hospice group), and yielded less money in charitable donations than the “direct-to-hospice” group.
At most institutions, cognitive specialties such as palliative medicine are not self-sustaining financially, and require subsidy from cost-savings or downstream revenue. PC suffers from low reimbursement for taking care of complex cases (ie, patients with a high symptom burden, patients and families confused about prognosis and goals of care, and lack of communication among multiple specialists already involved in care). This situation has led to the decline of other specialties similar to PC. As one example, the number of medical geneticists has declined from a high of 252 in 1993 to 135 in 2009. Geriatrics is barely surviving as a specialty because of poor reimbursement; about one-third of all fellowship slots are unfilled, and 66% of the fellows are international medical graduates, such that there are not enough practitioners, leaders, or researchers to sustain the field. This poor level of reimbursement affects APNs as well, as the money earned from usual billing is not sufficient to support their salaries. A PC nurse practitioner model program generated less than half the income needed to support salaries from “fee for service”; it could be self-sustaining if it generated program revenue by increasing hospice referrals, and if the hospice in turn supported the APN (but this may violate Starke regulations). Regardless of increased referrals, the program was closed after 2 years. More models of integrated PC–oncology programs and comprehensive assessment of best practices in this context are clearly needed.
Cassel et al described the impact of a PC outpatient clinic on a small rural health system. In general, the PC physician could cover her salary as an internist. The hospital saved $80,000 to $120,000 a year on Medicare admissions by the shorter patient length of stay (about 0.5 days) and fewer daily costs of the diagnosis-related groups (DRGs). Figure 1 shows the reduction in daily cost. The PC patients cost less to society, as shown in Figure 2, while in-hospital mortality did not change, as shown in Figure 3.
Several programs in cancer centers offer successful models of concurrent PC and oncology care. The most readily applicable one is the US Oncology model, which provides a PC physician or APN within an oncology practice. This appears to have a good effect on symptom scores, and it benefits the practice. Truly interdisciplinary care including a chaplain, social worker, and psychologist is difficult given the medical reimbursement model in the US.
Financial Disclosure: The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.